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Qualitative and quantitative assessment of infraoccluded deciduous teeth: a systematic review

Head & Face Medicine volume 20, Article number: 65 (2024) Cite this article

Abstract

Background

Infraocclusion of deciduous teeth is a frequent dental anomaly caused by ankylosis accompanied by local growth disturbance. During puberal growth spurt an increasing progression of infraocclusion is detected. The clinical classification of ankylosed deciduous teeth varies considerably among scientific studies. The aim of this paper is to present an up-to-date overview of the variety of methods.

Methods

The systematic literature search followed the PRISMA guidelines and included the analysis of the following databases and study registries: PubMed (MEDLINE), the Cochrane Library, Web of Science, Embase.com and ClinicalTrials.gov from database inception until September 23, 2024. Studies that investigated at least one ankylosed deciduous tooth per participant in a quantitative or qualitative manner were included. Studies that evaluated only histological data were excluded. Controlled and uncontrolled clinical studies, retrospective studies, observational studies and cross-sectional studies were included. The studies were restricted to English and German languages. Case reports, case series, comments, expert opinions, letters to the editor, literature reviews and studies enrolling less than 10 patients or 10 infraoccluded teeth in total were excluded.

Results

Of 5645 records, 42 papers qualified for the final analysis. The evaluation of infraoccluded deciduous teeth was mainly (n = 37) performed by quantitative and semiquantitative assessment of the extent of infraposition at the occlusal level. The measurement reference differed considerably. Fewer studies have analyzed ankylosed deciduous teeth at the alveolar level by examining the contour of the alveolar ridge (n = 7) or the height of the alveolar process (n = 5). Even fewer studies (n = 4) have performed qualitative analysis at the skeletal level by evaluating the influence of the vertical skeletal growth pattern on the incidence of ankylosed deciduous teeth.

Conclusions

To carry out a comprehensive evaluation of infraoccluded deciduous teeth, an assessment of the occlusal, alveolar and potentially skeletal levels is advisable. Radiographic investigations i.e. panoramic radiographs are therefore essential as a supplement to clinical examination. There is a need for standardization and objectification of the methods for the classification of infraoccluded deciduous teeth to give a general recommendation of clinical performance.

Registration

This systematic review has been registered in the international prospective register of systematic reviews (PROSPERO) under the registration number: CRD42024555842.

Peer Review reports

Background

Infraocclusion of deciduous teeth is a frequently occurring dental anomaly caused by partial or complete dissolution of Sharpey’s fiber apparatus. Due to fusion of the alveolar bone with the root cementum, affected deciduous teeth do not participate in vertical growth and thus appear increasingly infraoccluded. The cause of ankylosis is still not well understood. Degenerative changes in the periodontium in combination with a genetic background are suspected [1]. The prevalence of infraoccluded deciduous teeth varies significantly from 0.07 to 24.8% in the literature [2,3,4,5]. The highest prevalence is described at the ages of 8 and 9 years [1]. While a decrease in the mild form is described with increasing age, there is an increase in the moderate form in 8- to 10-year-olds and the severe form in 11- to 13-year-olds [5].

Infraoccluded deciduous teeth can lead to negative consequences in the long term. Affected teeth sometimes exfoliate late or even require surgical removal [6]. There is a local growth disturbance and an increasing progression of infraocclusion, especially during the puberal growth spurt [7]. The affected teeth may influence the occlusion: there is a risk of overeruption of the antagonist, a shift in the dental midline to the affected side and distal position of the first permanent molar [8, 9]. With pronounced infraocclusion, Becker and Karnei-R’em [10] demonstrated increased tilting and eccentric root movement of neighboring teeth. In addition, neighboring teeth are often undererupted [10]. The extremely early onset of infraocclusion can result in developmental disorders of the successor in the form of malformations, delayed tooth maturation and displacement [11].

A well-founded diagnosis is essential for assessing the development and therapeutic consequences of infraoccluded deciduous teeth. To date, the literature does not present any standardized diagnostic procedures for the quantitative and qualitative assessment of infraoccluded deciduous teeth. The extent of infraposition has been measured very frequently, but reference levels differ [8, 12,13,14]. Hvaring and Birkeland [15] introduced relative measurements to account for different magnification factors of panoramic radiographs. In contrast, other authors used the semiquantitative classification of infraoccluded deciduous teeth [6, 16, 17]. In addition to dental observations, analyses of the contour of the alveolar ridge [18, 19], the alveolar bone height [10, 11, 20] and the skeletal growth pattern [21, 22] were carried out. Studies on the etiology of infraocclusion of deciduous teeth often use histologic examinations [1, 17, 23].

In addition, numerous secondary parameters for the study of infraoccluded deciduous teeth have been described in the literature. The extent of root resorption [12, 24, 25] and the influence of ankylosis on the tilting of neighboring teeth [12, 26,27,28] have frequently been analyzed. Other studies investigated the influence of the length of the dental arch [8, 9]. Numerous studies also focused on the formation, position, development and eruption of the successor [6, 11, 20, 25] and its association with other dental anomalies, such as aplasia, supernumerary teeth, microdontia, displaced canines, enamel hypoplasia, taurodontism and odontomas [14, 22, 29, 30].

The aim of this systematic review is to detail the current state of the literature on the qualification and quantification of infraoccluded deciduous teeth. This work focused on assessing the extent of infraocclusion at the occlusal, alveolar and skeletal levels. The establishment of a standardized classification is intended to simplify treatment decisions regarding the extraction or observation of affected deciduous teeth and to improve the evaluation of long-term prognosis.

Methods

This systematic review was based on the current Preferred Reporting Items for Reporting Systematic Reviews and Meta-Analyses (PRISMA) guidelines [31, 32]. The review has been registered in the international prospective register of systematic reviews (PROSPERO) under the registration number: CRD42024555842. The protocol has not been published. Studies that investigated at least one infraoccluded deciduous tooth per participant quantitatively or qualitatively were included. Histologic investigations and secondary parameters discussing the consequences of infraoccluded deciduous teeth on adjacent teeth, dental arches or successors were not included in the study. Controlled and uncontrolled clinical studies, retrospective studies, observational studies and cross-sectional studies were included. Case reports, case series, comments, expert opinions, letters to the editor, literature reviews and studies enrolling less than 10 subjects or 10 infraoccluded teeth in total were excluded. All articles were limited to English and German languages. An electronic search was conducted on the following databases:

  • PubMed (MEDLINE including MEDLINE In-Process) (January 1, 1948 to September 23, 2024);

  • Cochrane Central Register of Cochrane Reviews and Controlled Trials (CENTRAL) (January 1, 1992 to September 23, 2024);

  • Web of Science Core Collection.

  • Science Citation Index Expanded (January 1, 1900 to September 23, 2024);

    • Social Sciences Citation Index (January 1, 1956 to September 23, 2024);

    • Arts & Humanities Citation Index (January 1, 1975 to September 23, 2024);

    • Emerging Sources Citation Index (January 1, 2019 to September 23, 2024);

  • Embase.com (Elsevier) (January 1, 1974 to September 23, 2024).

Study registries (ClinicalTrials.gov) were searched (to September 23, 2024), and corresponding authors were contacted if information was missing. The search strategy was developed and monitored by an expert consultant (SW). A detailed list of the search strategy is provided (see Additional file 1). The identified publications were imported into Endnote (version X7.8, Clarivate, Philadelphia, PA), and duplicates were eliminated using the deduplication tool. The remaining duplicates were checked and removed manually. Based on the title and abstract, one investigator (TT) preselected n = 156 potentially relevant publications. The findings were independently verified by a second investigator (HKS). Disagreements on n = 5 publications were discussed, and a consensus was reached. In the end, n = 151 reports were selected for retrieval. A standardized protocol was developed for the analysis of the full texts (see additional file 2). Full-text documents of all relevant papers were analyzed using this protocol by one investigator (TT) and verified by a second investigator (HKS). Disagreements on n = 3 publications were discussed, and a joint consensus was reached on the final included publications (n = 42). A standardized questionnaire was developed to analyze the study characteristics. Initially, all data from the individual studies were extracted by one investigator (TT) based on the questionnaire (see additional file 3). These were discussed in detail between both investigators (TT, HKS) and a final decision was made based on the inclusion criteria. The following parameters regarding infraoccluded deciduous teeth were extracted in the end (see Table 1):

Table 1 Definitions of the individual parameters surveyed. Each column is to be read separately from top to bottom
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Results

Initially, 5645 records were found via an electronic literature search. After duplicate removal, 4103 records were screened, of which 144 full-text documents were reviewed, and 42 papers were ultimately included (see Fig. 1). Table 2 shows the characteristics of the individual studies. Additional file 4 presents a detailed list of the 102 excluded papers.

Fig. 1
figure 1

Flow diagram presenting the study selection process according to PRISMA guidelines

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Table 2 Summarized data of the included studies in the review
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Discussion

Various treatment decision models have been introduced in the literature, which are primarily based on the degree of infraocclusion (mild, moderate, severe), root resorption level, tilting of the adjacent teeth and agenesis or no agenesis of the successor [33,34,35]. However, the degree of infraocclusion alone is not always associated with the severity of ankylosis or its effect on the alveolar process [11]. Furthermore, studies have shown a lack of correlation between root resorption and the long-term prognosis of deciduous teeth [36, 37]. Whereas tilting of the adjacent teeth is a secondary dental effect [26]. The development of the successor, however, is decisive in the evaluation of infraoccluded deciduous teeth. Normal exfoliation of affected teeth with a successor is likely without the need for treatment intervention [8]. Exfoliation of affected teeth without a successor is unlikely and a more pronounced infraposition is expected instead [38]. Infraoccluded teeth without successor are therefore critical to assess.

In all treatment decision making models growth is not taken into account. The increase of the infraposition of infraoccluded deciduous teeth correlates with the rate of growth [17]. The evaluation of the extent of growth inhibition is therefore important for an appropriate therapeutic approach, in addition to the consideration of the development of the successor. In the present study, the focus therefore was placed on the various assessment levels of infraoccluded deciduous teeth, with particular attention to the influence on alveolar growth (see Fig. 2). In the vast majority of studies (n = 37), affected teeth were assessed at the occlusal level (see Table 2). Significantly fewer studies assessed infraoccluded deciduous teeth at the level of the alveolar ridge (n = 7) or the alveolar process (n = 5). Qualitative examination of the vertical skeletal growth pattern was performed even less frequently (n = 4).

Fig. 2
figure 2

Visualization of the assessment of infraoccluded deciduous teeth using a stage model: While the color green indicates the assessment of infraoccluded deciduous teeth at the occlusal level (= occlusal offset), the color purple reflects the assessment of the contour of the alveolar crest (= alveolar ridge), the color yellow the height of the mandible (= alveolar process), and red the vertical mandibular growth pattern initiated by condylar growth (= skeletal growth pattern)

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The occlusal offset was mainly evaluated by metric measurements (n = 23). Fewer studies assessed the extent of infraocclusion using semiquantitative categories (n = 13). N = 1 study investigated the extent of the infraposition of deciduous teeth exclusively by clinical examination [23]. The reason given by the author was the variability of the occlusal plane as a reference plane, which depends on the inclination of individual teeth, the extent of attrition, the curve of spee, the eruption stage and the number of teeth in the quadrant. The advantage of categorization lies mainly in the ease of use and the subordinate role of standardization of radiographs. However, the nature of the ordinal scale must be taken into account in the statistical analysis [39]. In addition, the categorization is based on subjective observations, therefore a number of studies used categories based on previously performed metric measurements (n = 5). With the exception of one study by Hvaring and Birkeland [15], the metric measurements were always absolute measurements (see Figs. 3 and 4). The advantage can be attributed to its simple application and statistical evaluation. However, the reference levels differed between the studies (see Table 3). This makes it much more difficult to compare the measured values from different studies. In addition to the limitations imposed by the variability of the occlusal plane as a reference plane, the use of panoramic radiographs is compromised by the effects of magnification, distortion, and motion artifacts. Consequently, Hvaring and Birkeland [15] introduced the relative measurement of infraocclusion (see Fig. 5). However, the dependence on the crown length of the first permanent molar and the difficulty in marking the cementoenamel junction should be noted [40]. Becker and Karnei-R’em [10] found the first permanent molar adjacent to an ankylosed deciduous tooth to be an unsuitable reference due to evidence of undereruption. While older studies prior to the year 2000 primarily used non-radiographic methods such as clinical examination or cast analysis to determine the extent of infraocclusion of deciduous teeth at the occlusal level, the use of radiographic methods increased significantly in studies after the year 2000.

Table 3 Overview of several definitions of the occlusal plane as a reference plane for evaluating the extent of infraoccluded deciduous teeth used in scientific studies
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Fig. 3
figure 3

Determination of the extent of infraocclusion according to Kurol and Thilander [8] by measuring the shortest distance from the ankylosed deciduous tooth to the occlusal plane (the mesiobuccal cusp of the first permanent molar to the incisal edge of the incisors)

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Fig. 4
figure 4

Determination of the extent of infraocclusion according to Shalish et al. [14] by measuring the shortest vertical distance from the distal marginal ridge of the ankylosed deciduous tooth to the mesial marginal ridge of the first permanent molar. The second deciduous molar is 2,5 mm infraoccluded

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Fig. 5
figure 5

Relative measurement of the infraocclusion of an ankylosed second deciduous molar according to Hvaring and Birkeland [36]. The y-axis is defined as the distance b: distance from the mesial cementoenamel junction to the mesial cusp tip of the first permanent molar. The x-axis runs perpendicular to the y-axis. Infraocclusion is presented as the ratio (R = a/b), which describes the ratio of the shortest distance from the most prominent distal cusp of the ankylosed deciduous tooth to the x-axis (distance a) to the crown height of the first permanent molar (distance b)

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The analysis of the alveolar ridge is a radiologic method for the evaluation of infraoccluded deciduous teeth, in which intraoral images (intraoral films, bitewing images) and panoramic radiographs are used. When examining the contour of the alveolar ridge, Kurol and Koch [42] found that infraoccluded deciduous teeth in situ showed a concave curve that normalized after exfoliation. However, other authors have focused on the distance from the cementoenemal junction to the alveolar bone ridge. Mass et al. [18] detected a reduced distance in affected deciduous teeth (see Fig. 6). Kurol and Olson [45] evaluated the attachment loss of the first permanent molar five years after exfoliation or extraction of infraoccluded second deciduous molars. In accordance with Peretz et al. [19], the authors found no association between the extent of infraocclusion and alveolar bone loss. In contrast, Messer and Cline [6] detected a risk for successors in terms of underdevelopment of the alveolar bone and periodontal pocket formation. Particularly premolars associated with retained infraoccluded deciduous teeth and infraoccluded deciduous teeth requiring extraction were affected.

Fig. 6
figure 6

Assessment of the distance of the cementoenemal junction to the alveolar ridge according to Mass et al. [18]: 1 = distal surface of the adjacent mesial tooth, 2 = mesial surface of the infraoccluded tooth, 3 = distal surface of the infraoccluded tooth, 4 = mesial surface of the adjacent distal tooth

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Studies that analyzed the alveolar bone height using panoramic radiographs showed an inhibition of vertical growth in the region of infraoccluded deciduous teeth and adjacent teeth (see Fig. 7). Kjaer et al. [11] observed a reduction in alveolar bone height in the region of affected deciduous teeth with increasing infraocclusion, except for patients with extremely early onset and therefore severely affected teeth. Dias et al. [44] also confirmed a reduction in vertical alveolar bone growth in the first permanent molars and second premolar region over time using a subtraction method. Deviations were detected by the superimposition of two panoramic radiographs with a minimum time interval of one year using the inferior border of the mandible and the mesiodistal width of the first permanent molar as fixed points. Becker and Karnei-R’em [10] examined in detail the undereruption of neighboring teeth in combination with the change in inclination of the neighboring teeth. Kurol and Thilander [20] compared the alveolar bone height of bilateral infraoccluded deciduous teeth with unilateral aplasia and found no difference in height. All studies analyzing alveolar bone height were limited to the lower arch only. No study assessed the influence of infraoccluded deciduous teeth on vertical growth in the upper arch.

Fig. 7
figure 7

Determination of the alveolar bone height by a) measuring the distance from the center of the occlusal surface of the adjacent teeth to the inferior border of the mandible, parallel to the skeletal midline according to Becker and Karnei-R’em [10], b) measuring the shortest distance from the alveolar ridge to the inferior border of the mandible through the midpoint of the cervical mesio-distal diameter of the ankylosed deciduous tooth according to Kjaer et al. [11], and c) measuring the shortest distance from the most coronal point of the furcation of the first permanent molar to the inferior border of the mandible according to Kurol and Thilander [20]

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A more far-reaching, qualitative approach to the evaluation of infraoccluded deciduous teeth was chosen by Brown [46], Kula et al. [47], Leonardi et al. [22] and Lanteri et al. [21]. The authors examined vertical skeletal parameters to identify skeletal growth characteristics. The studies reveal contrasting findings. While Leonardi et al. [22] found significant anterior rotation of the mandible in patients with affected deciduous teeth in a longitudinal study, the latter authors indicated a possible posterior rotating mandibular growth tendency. Brown [46], on the other hand, found no significant difference between patients with infraoccluded deciduous teeth and a control group in terms of the ratio of anterior to posterior facial height (see Fig. 8). Kula et al. [47], however, found a tendency towards a larger anterior than posterior facial growth in patients with infraoccluded deciduous teeth. A vertical growth pattern is associated with increased alveolar remodeling [48]. An increase in the infraposition would therefore be expected. The growth pattern may therefore be important in predicting the development of infraocclusion of deciduous teeth. However, the discrepancy in the results does not confirm this. The heterogeneity may be due to the study design and the different use of the cephalometric analysis.

Fig. 8
figure 8

Cephalometric analysis showing the landmarks (N = nasion, G = gonion, M = menton, ANS = anterior nasal spine, PNS = posterior nasal spine) and construction lines (AFH = anterior facial height, PFH = posterior facial height, AMH = anterior maxillary height, PMH = posterior maxillary height) according to Brown [46]

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In conclusion, there is a lack of standardization in the analysis of the quantitative and qualitative assessment of infraoccluded deciduous teeth in scientific studies. This is the first scientific paper to assess affected deciduous teeth using a stepwise model at the occlusal, alveolar and skeletal levels. Nevertheless, limitations of the results must be taken into account due to the inclusion of studies with small cohorts. Due to time constraints, single pre-screening was performed for titles and abstracts. In addition, one author performed data extraction. A second reviewer verified the data. Because these steps were not performed by two independent reviewers, some risk of error may be introduced. In addition, the literature search was limited to publications to English and German languages. However, the methodological limitations are not expected to influence the conclusions of this review. The analysis shows that a single assessment of the occlusal level is not sufficient for a comprehensive evaluation of the extent and progression of infraoccluded deciduous teeth. The assessment of the alveolar ridge is essential due to the influence of ankylosis on the transseptal fiber arrangement and the associated changes in the contour of the alveolar ridge and the position of the adjacent teeth [26]. The alveolar process plays a significant role in assessing the influence of local disturbances of the periodontal ligament on growth. Clinically, this means that infraoccluded deciduous teeth with signs of alveolar growth retardation should be viewed critically. Especially in the growth phase, treatment in the form of extraction may be favored, particularly in cases without a successor. The thorough diagnosis of affected deciduous teeth is therefore of particular importance to paediatric dentists and orthodontists. In the future, treatment decision models should be expanded by clinically relevant parameters such as the assessment of alveolar bone growth. The benefit of evaluating the vertical skeletal growth pattern by cephalometric radiographs has not yet been clarified. Future research is needed.

Conclusions

  • Infraoccluded deciduous teeth affect both occlusion and vertical alveolar growth by influencing the surrounding tissues.

  • Most studies focus exclusively on the extent of infraposition when investigating infraoccluded deciduous teeth. The influence on alveolar and skeletal vertical growth is given less consideration.

  • There are no studies that have investigated the relation between infraoccluded deciduous teeth and alveolar growth in the upper arch.

  • The use of a stage model was implemented, which considers (1) occlusal extent of infraposition, (2) contour of the alveolar ridge, (3) height of alveolar process and (4) skeletal vertical growth pattern.

  • Clinical examination, cast analysis and panoramic radiographs are essential for a comprehensive diagnosis of infraoccluded deciduous teeth. Intraoral films are inappropriate due to missing representation of the alveolar process.

  • The development of standardized, objective parameters is necessary. This primarily concerns methods for evaluating the influence of infraoccluded deciduous teeth on alveolar bone growth in the upper arch.

  • When growth inhibition has occurred, extraction of the affected tooth is suggested, particularly during the growth phase and in cases without a successor.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

PRISMA:

Preferred Reporting Items on Systematic Reviews and Meta-analysis

PROSPERO:

International prospective register of systematic reviews

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  1. Department of Orthodontics, Clinic of Dentistry, Philipps University Marburg, Georg-Voigt-Str. 3, 35039, Marburg, Germany

    Teresa Temming, Anahita Jablonski-Momeni & Heike Korbmacher-Steiner

  2. Central Medical Library, University Library of Marburg, Philipps University Marburg, Conradistr. 3a, 35032, Marburg, Germany

    Susanne Waldmann

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TT and HKS reviewed the literature, participated in the study design, and drafted the manuscript. SW revised the literature review. AJM critically revised the manuscript. All authors gave final approval of the manuscript.

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Temming, T., Waldmann, S., Jablonski-Momeni, A. et al. Qualitative and quantitative assessment of infraoccluded deciduous teeth: a systematic review. Head Face Med 20, 65 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13005-024-00469-3

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Head & Face Medicine

ISSN: 1746-160X

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